Value-Based Care Is Key to Bringing Cardiology Breakthroughs to Those Who Will Benefit Most

Am J Manag Care. 2025;31(Spec. No. 3):SP162-SP165. https://doi.org/10.37765/ajmc.2025.89712

Opportunities to deliver cardiology care with a value-based mindset begin before heart failure is ever diagnosed and extend throughout the care journey to acute treatment, ongoing management, and rehabilitation, according to speakers at an Institute for Value-Based Medicine (IVBM) event in Dallas, Texas, on December 10, 2024. The event, held by The American Journal of Managed Care in partnership with Optum, featured faculty from the University of Texas (UT) and subsidiaries of Optum.

Event cochair Ken Cohen, MD, FACP, executive director of translational research at OptumCare, began the evening with an overview of value-based care in cardiology. He introduced the Optimal Care Model, which aims to reduce waste by putting the evidence in physicians’ hands that empowers them to practice at the best possible intersection of cost and quality. Specific to the event’s theme of cardiology, he provided the example of evaluating new-onset chest pain with the suspicion of coronary artery disease. Recent years have seen the advent of coronary CT angiography, which is becoming the gold standard for ischemia evaluation when combined with fractional flow reserve.1 This testing modality can reduce unnecessary stenting, and evidence suggests better outcomes in patients receiving this modality than those sent directly for cardiac catheterization.2,3

Cohen’s team is taking value-based care one step further by developing an algorithm that primary care physicians (PCPs) can use to determine a patient’s pretest probability of having coronary artery disease based on their age, sex, and medical history. Patients with a low probability are recommended to receive a noninvasive, low-cost, low-radiation coronary artery calcium scan, only moving onto the more intensive and costly testing modalities if they screen positive.

“The critical part of this algorithm is that it’s PCP driven, and it saves our cardiologists from seeing tons and tons of low-risk [patients with] chest pain who, frankly, shouldn’t be filling their schedule, and really allows them to focus on the patients who have hemodynamically significant disease, the ones who need to be seen by them,” Cohen said.

He then discussed value-based strategies for managing patients with existing coronary disease, which include following guidelines for ischemia testing, judiciously using electrocardiograms as preoperative testing, and selecting the optimal guideline-directed medical therapy. However, the use of guidelines can’t mean that the doctor loses sight of what the patient wants, he added.

Clinicians treating patients with heart failure need to understand those patients’ wishes “and then marry those goals and preferences with your management so that the issues that you bring to the patient and the recommendations that you make are completely concordant with their values and preferences,” Cohen said.

Next, Shreya Rao, MD, MPH, an assistant professor at UT Health Sciences Center Division of Cardiology in San Antonio, presented on how value-based care can help alleviate disparities in cardiology care for underserved populations. Using as an example a 43-year-old man with numerous social risk factors and worsening health, she explained that “the system has failed him when it comes to quality metrics in terms of addressing his acute symptoms, it’s failed him with regards to his long-term chronic health, and we’ve, if anything, exacerbated some of the chronic social issues that he already had. Despite that, we’ve billed him for those services time and time again.”

To break this pattern of failure, she said, clinicians and health care systems need to improve the type of care that patients like these are receiving. Some have touted value-based reimbursement models as the solution, but Rao noted that although they have improved outcomes across the board, their impacts on equity have been more nuanced. In fact, there are concerns that providers treating patients with high social risk are being unfairly penalized in value-based programs such as the Merit-based Incentive Payment System, with current risk-adjustment methods not fully accounting for social risk.

The central tension in conversations about value, Rao said, is how to “encourage high-quality care for the highest-risk individuals in our society while also maintaining accountability for good outcomes and cost-efficiency across the health care system.” There is no perfect answer, but Rao is encouraged by the design of CMS models such as Accountable Care Organization Realizing Equity, Access, and Community Health, or ACO REACH, which includes a health equity benchmark and robust data collection on social determinants of health.

Alongside the innovative payment models incentivizing value-based care, new care delivery approaches empowered by technology are also making a difference in cardiology, according to the next speaker, Michael Almaleh, MD, FACC, a cardiologist at WellMed Medical Management in San Antonio. He presented on how remote patient monitoring can help providers manage cases of moderate to severe heart failure in the outpatient setting. This is an area of great unmet need, Almaleh said, as heart failure is costly, results in significant hospitalizations, and greatly reduces life expectancy.

Despite the advances in pharmacologic therapies for heart failure, mortality rates are worsening because these therapies are not properly utilized, Almaleh said. One way to address this gap is through remote patient monitoring, which can be as simple as calling patients to ask how they feel and have them report their heart rate or as advanced as remote measuring of bioimpedance or hemodynamics. A recent meta-analysis of several studies of remote monitoring found that outcomes depended on the intervention.4 Measuring blood pressure, measuring weight, and using a tablet or phone were the only remote interventions that resulted in reduced hospitalization and death. Also, combining these strategies used to prevent heart failure with remote monitoring for any other disease resulted in a loss of benefit. “What we learned there is that if you’re trying to be a jack of all trades, you wind up being a master of none,” Almaleh said.

He provided a case study of a heart failure clinic that he helps manage in Dallas that uses remote patient monitoring to contact patients, triage them according to symptoms, and focus attention on those who are most likely to need a hospital visit soon. The exact platform used to connect to patients is less important than the act of contacting patients at all, he noted. Data from another clinic in San Antonio have shown a decrease in medical costs the year after patients enroll in the monitoring program that persists for multiple years, as well as a decrease in hospital admissions.

The overall goals of these heart failure programs are to provide high-value care that results in “patient education and self-care management, guideline-directed medical therapy,… early symptom detection and therefore prevention of hospitalization and [emergency department] visits, reduction in medical costs, prolonged life, and improved quality of life. We’re generally able to see that in each of our markets that has heart failure programs,” Almaleh said.

The next speaker, event cochair Ambarish Pandey, MD, MSCS, FAHA, an associate professor at UT Southwestern Department of Medicine in Dallas, took a different angle: value-based care approaches for the prevention of heart disease. “Identifying patients with diabetes who are most likely to develop heart failure could actually help allocate expensive therapies to those who need it the most,” Pandey said, “and this risk-based approach to heart failure prevention could be most value-based for our health system, considering the financial constraints around use of these expensive therapies.”

Amino-terminal pro B-type natriuretic peptide (NT-proBNP) level is one of the strongest predictors of heart failure risk, according to Pandey, and adding these levels to clinical risk scores has been shown to significantly improve risk prediction performance.5 This benefit extends to clinical outcomes, as other trials have shown lower rates of adverse outcomes in patients who received BNP-guided care, driven by an increase in use of angiotensin receptor blockers.6,7 The problem now is uptake, using clinical risk scores and biomarkers together to predict heart failure in an efficient and cost-effective manner.

To provide a road map for a pragmatic approach, Pandey and colleagues published a review article that offers recommendations to help clinicians overcome the challenges in implementing new prevention strategies.8 A key component is a 2-step screening strategy consisting of clinical risk score determination followed by selective biomarker or echocardiogram testing for those at low or intermediate risk to determine true risk and need for intervention.

“Such a complementary, sequential approach of testing can indeed pave the way for a value-based care approach for heart failure prevention in diabetes and for implementation of expensive therapies like SGLT2 [sodium-glucose cotransporter 2] inhibitors, finerenone, and GLP-1 [glucagon-like peptide-1] agonists that are coming to the forefront for prevention of cardiovascular disease in the patient population with diabetes,” Pandey said.

Value can also be found in the underutilized tool of cardiac rehabilitation, according to the final speaker, Neil Keshvani, MD, a cardiologist at UT Southwestern Medical Center in Dallas. Patients with heart failure with preserved ejection fraction are often unable to perform activities of daily living, leading to frailty, impaired quality of life, and worse health outcomes. Cardiac rehabilitation, which encompasses medication adherence, risk factor reduction, psychosocial support, and physical exercise, has been shown to improve key functioning end points and quality of life, although evidence of its effect on all-cause mortality and hospitalization risk is mixed.

Current heart failure care guidelines recommend exercise training and cardiac rehabilitation, but utilization remains low, in part because of co-pay costs and logistical challenges. Inclusion criteria also limit the eligible patients to those with chronic, stable heart failure with reduced ejection fraction, but Keshvani argued that patients with preserved ejection fraction who are frail or have recently been hospitalized are actually most in need of rehabilitation and often are not receiving it.

“The current heart failure cardiac rehabilitation paradigm does not represent high-value care, and we need major reforms on how we prescribe cardiac rehabilitation and to whom we prescribe it so that we can give the therapy needed to patients who need it the most,” Keshvani said.

Closing out the event, the speakers held a panel discussion to answer questions from the audience. In response to a question about primary care involvement in cardiology care, Pandey noted that his team at UT Southwestern is striving to “identify strategies that can help us with aiding the PCPs in identifying high-risk patients without necessarily adding extra burden on them,” such as a virtual cardiometabolic clinic program for e-consultations. Rao added that PCPs working in tandem with community health workers and pharmacists can help address social barriers to care. “This is a model we’re really interested in studying to try to demonstrate the efficacy of providing that ancillary support to [PCPs] to improve quality of care,” she said.

One important barrier to a healthy lifestyle is food insecurity, according to Keshvani, who highlighted his team’s initiation of a program to deliver fresh groceries, healthy meals, and nutrition education to recently hospitalized patients with heart failure. Forthcoming results “hopefully by next year will tell us [whether] this is an approach that’ll work, and then definitely looking forward to economic analyses in the future, which [will tell us], if it does work, what’s the cost to prevent an event.”

Finally, Cohen and Almaleh touched on the difficulty of measuring a key component of value: quality of life. Almaleh said that the Minnesota Living With Heart Failure Questionnaire score helps quantify how a patient feels, but cardiology could take a cue from other specialties that can identify patients who are candidates for surgery based on their quality of life and patient-reported outcome measures: “That’s the granular level of detail that we need to start collecting.”

Author Information: Ms Mattina is an employee of MJH Life Sciences, the parent company of the publisher of Population Health, Equity & Outcomes.

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